Thursday, July 30, 2009

Doctors Support Healthcare Reform

Not every doctor, certainly, but this video shows some of the reasons why so many doctors DO support reform.

Unaffordable Private Health Insurance

The Commonwealth Fund has an interesting report re: the real-life availability of privately-purchased health care insurance in the US right now. I've copied in the abstract and overview below; the full report is available here.

The key points to me are that individuals who sought insurance on their own in the current marketplace were largely unable to purchase affordable plans, and even in the case of employer-provided plans there were issues of access.

A public insurance plan would provide an alternative to these over-priced and unaffordable plans. Without that, how would these policies be made more affordable and avaiable? I just don't see that the private market alone can compensate for this, otherwise wouldn't already be doing so?

Obviously, this doesn't even begin to address whether the unaffordable plans actually provide any significant/meaningful benefits...


Failure to Protect: Why the Individual Insurance Market Is Not a Viable Option for Most U.S. Families

Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2007
Michelle M. Doty, Sara R. Collins, Jennifer L. Nicholson, and Sheila D. Rustgi

ABSTRACT: Between 2001 and 2007, an increasing share of adults with private insurance—whether employer-based coverage or individual market plans—spent a large amount of their income on premiums and out-of-pocket medical costs, were underinsured, and/or avoided needed health care because of costs. Those with coverage obtained in the individual market were the most affected. Over the last three years, nearly three-quarters of people who tried to buy coverage in this market never actually purchased a plan, either because they could not find one that fit their needs or that they could afford, or because they were turned down due to a preexisting condition. Even people enrolled in employer-based plans are spending larger amounts of their income on health care and curtailing their use of needed services to save money. The findings underscore the need for an expansion of affordable health insurance options, particularly during a time of mounting job losses.


Employer-based health plans are the predominant form of health insurance for U.S. working-age adults and their families. Over the last decade, however, the relentless annual growth in health care costs and premiums has made it increasingly difficult for employers—especially small businesses—to continue providing comprehensive benefits. The current recession, and the sluggish economic growth that preceded it, has only exacerbated this troubling trend.

Employers are responding to rising health care costs and declining economic growth by dropping coverage altogether, or by shifting to less-generous benefit plans that require workers and their dependents to pay more out-of-pocket for their health care The increase in the unemployment rate over the past year means that more and more Americans have lost their job-based health benefits.

For people who do not have employer coverage, the options for affordable health coverage are very limited. If they should lose their job, workers in firms with 20 or more employees can purchase, through COBRA, coverage from their former employer at the full premium; a federal subsidy of 65 percent of premiums is temporarily available through the American Recovery and Reinvestment Act of 2009 (ARRA).2 Coverage through state public insurance programs like Medicaid and the Children’s Health Insurance Program (CHIP) in most states is limited to children, pregnant women, and parents with low incomes, with less than half of states covering any adults without children. This means that people who work for companies that do not offer health insurance are largely limited to purchasing coverage directly in the individual market. People who buy coverage in the individual market must pay the full premium and, in most states, are rated on the basis of their health
or age—and can be denied coverage because of a preexisting condition.3

Drawing from the Commonwealth Fund 2007 Biennial Health Insurance Survey, this analysis compares the experiences of adults ages 19 to 64 who purchased coverage in the individual insurance market with adults covered by employer-based plans. It finds that nearly half (47%) of adults who tried to purchase insurance in the individual market in the last three years found it very difficult or impossible to find a plan that fit their needs; 57 percent found it very difficult or impossible to find a plan they could afford; and 36 percent said they were turned down or charged a higher price because of a preexisting condition. Nearly three-quarters (73%) of respondents said they never bought a plan, with 61 percent of those who did not buy a plan in the individual market citing expensive premiums as the main reason. Adults who do purchase coverage in the individual market pay more out-of-pocket for their premiums, face much higher deductibles, and spend larger
shares of their income on health insurance and health care expenses than their counterparts with employer-based group coverage.

The analysis also finds that between 2001 and 2007, an increasing share of adults with private insurance—whether employer-based plans or individually purchased plans—spent a large portion of their income on out-of-pocket medical costs and premiums, became underinsured, and/or avoided needed health care because of the cost. Adults with coverage obtained through the individual market were the most affected.

These findings indicate that the individual insurance market in its current form does not provide a viable alternative to employer-based group coverage. It also shows that even people in employer-based plans are spending increasing amounts of their income on health care and curtailing their use of needed services as a result. New, affordable health insurance options are needed for Americans who are currently uninsured or underinsured and for those who will lose access to employer-based benefits during the recession.

Friday, July 24, 2009

Questions For Conservatives

So, a few questions for conservatives out there:

--If you want a private marketplace for insurance plans (without a public plan or government subsidies), how are the working poor and minimum-wage workers supposed to buy insurance?

--If you do not want required minimum level of benefits (set by an expert panel or some other agency), how could you ensure that the offered plans will provide the necessary benefits?

--Assuming plans offer needed care and the money is somehow available, how will patients be able to choose a plan that will meet THEIR needs? Medicare Part D created a large problem in terms of choosing the right plan—and that was for a single health insurance benefit. How are patients supposed to choose among the dozens of benefits (preventive care coverage, medication coverage, etc) without help? And who will help them? The for-profit insurance companies?

--How would this address the issues of budget and cost overruns for the current government plans (Medicare/Medicaid)? Even if we assume that an envisioned private insurance market would work, it seems we are still privatizing profits while socializing risk—just as Wall Street and the financial markets have done, much to all of our distress.

--What sorts of incentives or changes would be considered to minimize unnecessary expenses? Would the relative effectiveness research being proposed by the current administration still be promoted? Or will the options of continuing expensive treatments or interventions that have not been proven to be better than less expensive choices be left alone to continue without change?

I would think these challenges would be daunting to anyone addressing health care reform, but I guess I just do not see any way that the private-only market plan addresses this. Tax cuts/credits are nice, but how much will this really help a minimum-wage employee? Will this somehow provide enough money to purchase an insurance plan that really could promote health?

I just don’t see it.

Wednesday, July 22, 2009

A Fair Discussion

Recently, I have been exchanging e-mails with a colleague on an organizational mailing list (and probably annoying members of said list--sorry!). This is a reply to a graphic that was e-mailed to me. I think it is really interesting in the use of language: check out the two halves of the graphic and tell me if you can guess which side is favored. Here's my reply:


The graphic you sent is interesting--but I think it shows the difficulty in figuring out the best choices and the strengths and weakness of the various options.

The image on the left, the "Consumer-Centered System" highlights as a strength what I think is the greatest risk in the system: Consumers decide what health plan suits them best. I readily admit that many consumers could make this decision--but many, many would struggle to choose a reliable and beneficial plan without significant assistance. We've seen w/ the current subprime mortgage market that people can get themselves in terrible trouble by making bad decisions--many misled, some dishonest. However, when these decisions add up and the system collapses, you risk having a situation where you have exactly what we have now: many uninsured, many who pay for plans they can't get out of, many whose plans do not live up to benefits promised or perceived.

Interestingly, this graphic doesn't even account for any sort of government subsidy or tax break to help individuals fund their purchase. You would assume that patients would try to find the most affordable plan, but would they reliably recognize the limits on coverage that would almost certainly be present. The graphic also takes out any sort of employer-provided health care (it notes that families and individuals would choose their plans); so all the cost falls directly on families? Are employers supposed to pass the savings along to employees to allow them to buy insurance? It seems that this set-up would be riskier than the flawed system in place.

The graphic also doesn't address the issues of cost-shifting where the highest-need and highest-use patients would still likely be covered on government plans which still would not be able to recover costs by insuring healthier, lower-utilization patients.

I guess I just don't see how that model would address the issues of the unerserved or the issue of costs. In the long run, wouldn't we just end up pretty much where we are?

At the same time, the "Government-Driven System" graphic shows all the fears incumbent in any public insurance option: "politicians, bureaucrats in control at top", private plans can't compete, etc. My current understanding of legislation including HR 3200 doesn't fit with that.

This second graphic also seems to indicate that government-mandated "essential benefits" are a bad thing. If we're going to have a marketplace (which is the model in HR 3200 and other proposals) that include a public plan, patients will have hundreds or thousands of plans to choose among. We've seen the challenges of choosing Part D options: how can patients reliably and easily choose between the hundreds of benefits that would be part of each and every plan. Is it bad to require all plans to have some essential features? Maybe things like periodic health maintenance visits (Paps, Mammos, lipids, colon CA screens etc)? Maybe some sort of catastrophic coverage (or an easy way to add this to a basic-level plan). Maybe coverage for some essential level of generic meds at least--how long can we depend on Wal-Mart, Target, etc? If/when their generic plans stop making $ by bringing shoppers in to the store, those plans are at great risk. To me this is
a little bit like requiring seatbelts, brakes, etc on cars: aren't there some things that are SO essential that they MUST be included?

Medicaid and Medicare are terrible payers--we all know this. But is this in part b/c they can't meet their budgets b/c of the cost-shifting referred to above (covering so many patients w/ high utilization and so few that are healthy low-users)? Could/would the payments be better if the budgets were healthier? Wouldn't enrolling more healthy people in a public plan move toward that direction? Couldn't US businesses be more productive if they COULD find a plan with low premiums? So far, private plans have failed terribly at this. Would a public option be better?

To me, the fundamental questions involve fairness. To me this means universal coverage that is portable and affordable and that provides meaningful benefits. I haven't seen it from the private plans and I haven't seen it from Medicare/Medicaid. But this is a chance to make a difference, to provide care for all and to reduce the costs associated w/ healthcare in the US. Maybe even get better outcomes for the $ (which we do very poorly compared to other industrialized democracies).

Other countries are successful with this--public plan w/ private plans co-existing in a market, with varying levels of government control and requirements. Can't we find a system that will work to cover everyone, while still providing physicians w/ a good environment to practice? I think we need both, and I think we need to make sure we're looking at physician issues: malpractice reform, payment re-structuring, supporting EHR implementation, etc. If we don't have docs, we won't have healthcare. But I really feel that the efforts at the federal level can work and I'm troubled that so much energy is being devoted to breaking them down without any great sense of a sustainable, viable alternative.


Thanks for reading.

Sunday, July 19, 2009

Why We Need Government Involvement In Healthcare Reform

Another blog post that actually started as a reply to an e-mail. I do not want to print the initial e-mail, as it was not intended for general release and I'm going to refer to the writer as Dr. X. This e-mail was sent to a mailing list with other physicians, which explains what might seem as cryptic references to a mailing list.


I am by no means a health policy expert, but I have some concerns about Dr. X's position that patients would be better off with a high-deductible catastrophic-illness insurance policy coupled with an HSA. I think this model of providing health care threatens to leave far too many patients without adequate coverage.

I have spend my career to date (not the longest career on this mailing list, but still...) working in underserved and marginalized communities. I have seen patients defer or delay care b/c they could not afford their insurance co-pays. This includes the 20% co-pays required by some private insurance plans as well as the $40 required by a university health system's patient assistance program. How would patients in these positions realistically be able to save enough to fund their HSAs to cover the potentially thousands of dollars required by a high-deductible plan? Is there proof that a drop in medical resource utilization when patients switch to an HSA is b/c patients are being more careful w/ their care (as Dr. X contends in her e-mail)? Or are people deferring needed care b/c they cannot pay the costs?

I also question whether the increased use of medical resources when patients are enrolled in public plans is simply a matter of "if you pay for it, we will do it". I suspect that in many cases, patients have put off important care because they were uninsured (or underinsured), only to try and catch up once they can afford to thanks to some sort of coverage. How many of us have had patients ask us to try and work with them in terms of their care and try to delay optional things until they have Medicare? And then we have to decide whether our recommendations are urgent and must be addressed despite the financial burden--or maybe we can wait a little while. How many of us have had patients show up after qualifying for Medicare or some other insurance and be faced with the challenge of not only controlling out-of-control chronic illnesses but also struggle to catch up with long-neglected health maintenance?

I am not proposing that there be a government committee of some sort to dictate care and I, personally, do not feel that the programs to show relative benefits of treatment would be used to promote valuable care and not to deny care. I may be optimistic on this, but remember that many of our current meds were approved based on their benefit vs. placebo (and not vs. other active therapies) and that many of our specialty-endorsed evidence-based practice guidelines are not always followed.

I suppose that I just feel that there can be a role for the government in controlling costs. If a public health insurance plan is included in the legislation and is unsuccessful, then the private plans will prove their superiority. Considering, though, that the administrative overhead for the for-profit insurance plans can be 6-8x that of the current public plans I think the private plans will have some work to do. We also have to address the fact that the public plans disproportionately insure those patients who will have the highest utilization (such as the elderly and the disabled) while private plans do not carry this burden. This means that, currently, private plans tend to have a favorable patient mix with more relatively healthy people than the public plans. If public plans were able to enroll these healthier, lower-utilization patients, I would suggest that premiums and costs could be lowered. Using the larger purchasing power of such plans, some costs (such as medications) could be lowered drastically.

Finally, we do need to keep an eye on ourselves. I DO NOT think that doctors are the problem, and I do not want to be accused or thought of as saying that this whole messed-up system is our fault. But we can do better. In a recent New Yorker article, Atul Gawande shows how physician practice styles can impact care ( Granted--much of this is the result of the inefficient health care system we currently are discussing. But, if we cannot honestly review and address issues of our practices that will inflate costs, then any reform of ANY kind is facing a steep uphill climb from the beginning.

Finally, we need to continue to work on reform that will address the primary care workforce shortfall. Someone once compared universal health insurance (with guaranteed access for all) without increasing the primary care workforce to giving everyone in town free bus tickets--but only having one bus. The issues of medical student debt, reimbursement for primary care physicians, and changing the model of primary care to allow for the complicated care-coordination and health-promotion roles played by primary care physicians need to be addressed in any health care reform.


Thanks for reading. Let me know what thoughts or comments you might have.

Sunday, July 12, 2009

Health Care Reform Letter

So, recently the Richmond Times-Dispatch (RTD) printed a letter to the editor which doubted the motivations of the current health care reform efforts in Washington.

I have a letter to the editor in reply, which I am going to send to the newspaper. I don't think they'll actually print it--it's long, and way to liberal for the RTD. So, I'm going to post it here so that I don't feel like I have wasted my entire day.


To the Editor;

I am writing in reply to a letter published July 6, 2009 in the Richmond Times Dispatch regarding the current administration’s health care proposal. In her letter, Ms. Kathy Dean raises a number of questions regarding health care reform legislation that is being considered. I would like a chance to address some of her points. I feel qualified to comment on this issue as I have spent my entire career working in medically underserved communities (urban and rural) where I have seen the harm and the challenges that result from the large number of uninsured and under-insured citizens of our country.

There is no doubt that the American health care system needs to be reformed. Currently, the United States spends nearly $7,421 per person on healthcare—equal to 16.2% of our nation’s GDP. They are projected to increase to 25% of GDP in 2025. These costs weigh heavily on businesses (employer-based family insurance policies cost employers an average of $12,680 yearly) and families (half of all personal bankruptcies are at least in part due to medical expenses, most of which involved people that had insurance when they first got sick). Despite these high costs, the health care we receive falls well short of desired goals. When assessed across 37 performance indicators, the United States healthcare system scored 65 out of a possible 100 points.

Despite Ms. Dean’s concern about the current legislation enacting “two separate health care systems—one for those with political clout and the rich who can afford to pay taxes on their gold-plated benefits, and one for everyone else”, we already have a healthcare that has dramatic inequalities. Currently, the division is between those who are insured and those who are not. Children who lack health insurance have decreased access to health maintenance services, including vaccinations, well-child check-ups, dental care and prescriptions. Adults who do not have insurance also receive less preventive care and typically suffer worse health outcomes if they get sick. Health inequalities are also notable among those Americans who have insurance: do you have a well-funded employer-supported plan that encourages check-ups and health maintenance, or are you limited to a plan that covers catastrophic illness or hospitalization and includes a sky-high deductible (which you had to choose to keep the cost affordable)? Let us not kid ourselves—the current system is terribly expensive, fails to provide adequate coverage for millions of Americans, and does not achieve its desired goals.

I think Ms. Dean raises some important questions; including whether there will be enough primary care providers to cover the new patients and who will determine the type of care patients receive. The answers to these questions will be determined by the legislation in question. Currently, it is clear that the administration recognizes the need to increase the number of primary care physicians in the United States to ensure that the workforce issue will be addressed. How to meet these needs, though, is still unclear and will not occur in the short-term. Medical students will need to be able to enter primary care careers while still being able to pay their medical school loans (which now average well over $150,000). This will require the current health care payment structure to be adjusted, and primary care physicians will need to be reimbursed for their work in a manner that fairly addresses the challenges of coordinating patient care, ensuring health maintenance, and dealing with needs of patients who present with multiple complicated medical problems. This will not be easy in light of the already-existing challenges to healthcare funding.

In terms of the types of care patients receive, this also has not been determined but as of now there has been no indication that any legislation coming out of Washington will involve rationing. In fact, the administration has made efforts to communicate that patients will be able to choose their physician and the patient/physician team will dictate care. No doubt that there will be some limits or conditions that will be enacted—prior authorizations, medical reviews, etc. However, these limits and conditions already exist in all commercial and government-funded health plans. There has been no indication of any dramatic shift from these models. The government will be funding research to help determine what treatments, medications, and interventions provide the most benefits and are most cost effective. However, there is no sign that the results of this research will dictate care or coverage.

Regarding illegal immigrants, there has been no sign that adults who immigrated here illegally will be covered under any government-provided options. Children who are present illegally may be covered under Medicaid and FAMIS under the Children’s Health Insurance Program (CHIP) legislation already enacted. Considering that this coverage provides for well-child visits and vaccines, which benefit the child while also protecting the community at large against communicable diseases, this coverage was politically viable. Adults are not likely to receive any such consideration, as much as I worry about the strain that will be placed on safety-net providers such as free clinics and emergency rooms once undiagnosed chronic illnesses such as high blood pressure, high cholesterol, and diabetes start to cause complications.

At this point, the public health insurance plan being discussed as part of the healthcare legislation is what appears to be causing the most discomfort among those who oppose the idea. According to polling by Health Care for America Now! (HCAN) the idea of a public health insurance plan is well received by a majority of Americans. This plan would work within the current marketplace to provide an option beyond the commercial insurance plans. This plan will allow for more equitable enrollment of people who are healthy and require relatively few health care interventions and those who require more health care resources. Currently, a disproportionately large number of patients who require more health care are enrolled in public plans (Medicare and Medicaid) while those who are less-frequent users are disproportionately enrolled in private plans. If a public plan enrolled Americans from both the high-use and the low-use groups then the costs of premiums would be lowered and more affordable. This option could also make use of the fact that government-run programs have historically had much lower overhead costs for administration purposes (around 5% or so for public plans) as compared to for-profit commercial plans (nearly 30%). In addition, a public plan could be structured to emphasize health maintenance and health-promotion (including consideration of ideas such as the patient-centered medical home) that will prevent illness while also increasing the appeal of primary care medical careers. The public plan could also emphasize health interventions that work and that are cost-effective, as opposed to promoting new and flashy medications and technologies that have little to no additional benefits but that are dramatically more expensive.

It is a shame that Ms. Dean questions whether party affiliation will affect health care, and that she invokes President Obama’s position on abortion to question the motivation and results of these health care reforms. This issue is too serious, will have too many long-term repercussions, and will affect too many people to get caught up in unfounded rumors. There is no call in the current plan for a single-payer national health plan (much to the distress of many who would support it and who can show evidence that such programs improve outcomes and reduce costs)—if the public health insurance plan that is being discussed is not viable, then it will fail in the marketplace. There has been no indication that party affiliation will have anything to do with the coverage one will receive. By developing a health care reform plan that intends to provide affordable coverage to everyone, the current administration is seeking to provide care to the most vulnerable members of our society while also making care available to everyone else: the working poor who represent a large proportion of the uninsured; the self-employed and small businesses who have to choose between paying exorbitant premiums to commercial plans or reduce or eliminate coverage for themselves and their employees; large corporations who face a built-in hurdle compared to other developed nations because American companies have to pay high costs for employee’s health insurance while carmakers in other countries do not have to face this challenge. In short, the current health care reform efforts present a chance to provide meaningful and valuable care for all while still allowing for individual plan choice and reducing costs.

There is no question that our current healthcare system is unsustainable. We pay far too much for much too little, and too many are left uncovered. We need to take full advantage of this opportunity and develop a long-lasting, improved system. This legislation will dictate healthcare in the United States for decades, and it needs to include coverage that would be available to everyone and that will focus on health maintenance, treatments that provide health benefits and are cost-effective, and that will be sustainable long into the future.


So, that's my perspective. I'm interested in any comments or thoughts, so please feel free to post some if you would like to.